Laparoscopic-guided transversus abdominis plane block following laparoscopic sleeve gastrectomy is associated with an earlier return to activity: a study of 271 patients.

BACKGROUND: The morbidly obese (MO) patient presents a unique challenge to pain control in the postoperative period due to associated comorbidities and the amplified impact of opiates. In order to reduce potential complications associated with narcotic use in the MO patient, multimodal analgesia has been advocated. In this study, we examined the effect of laparoscopic-guided transversus abdominis plane block (LG TAP) for further optimizing multimodal pain control. METHODS: This is a retrospective analysis of a prospectively collected database of 140 consecutive patients undergoing LSG without TAP block (pre-TAP group) compared to 131 patients undergoing LSG with LGTAP (TAP group). All operations were performed laparoscopically utilizing uniform clinical pathways. Baseline characteristics for both groups were comparable. Both groups received standardized anesthesia. Outcomes included time to postoperative ambulation, pain scores, PCA volume, length of hospital stay, utilization of oral opiate medications, and return to activity (RTA). RESULTS: Pre-TAP versus TAP groups were comparable, mean age 42 years (p = 0.99), women 81.4% versus 87.8% (p = 0.148), mean BMI (kg/m2) 46 versus 45 (p = 0.394). Most patients ambulated within 2 h after arrival to the floor (87.9% vs. 76.3%, p = 0.013). On postoperative day (POD) 1, mean reported pain score (0-10) was 4.50 vs. 5.06 (p = 0.063) and a mean PCA morphine used for 24 h was 26.3 mL versus 26 mL, p = 0.35. Mean days of postoperative opiate medication were 2.19 versus 1.24 (p < 0.001). Return to activity was 2.81 versus 2.08 days (p < 0.001). When controlled for age, BMI, OR time, PCA volume used, and average pain score, TAP block was an independent predictor of earlier return to activities (p < 0.001). CONCLUSIONS: LGTAP block following LSG is an additional valuable modality of pain control in the perioperative period. Our study shows that TAP block is associated with an earlier RTA and decreased opiate use in patients undergoing LSG.

Recurrent Intestinal Obstruction after Radiation Therapy: A Case Report and Review of the Literature.

INTRODUCTION: In patients who have undergone resection for rectal cancer after neoadjuvant radiotherapy, loop ileostomy is commonly performed with few serious complications. In rare cases, if this irradiated small bowel is strictured, reversal of the affected ileostomy can have dire consequences. We present a case of a 62-year-old male with recurrent intestinal obstruction after closure of his loop ileostomy. CASE REPORT: RC is a 62-year-old male who initially presented with rectal cancer and underwent neoadjuvant chemoradiation prior to a laparoscopic low anterior resection with diverting loop ileostomy. He underwent elective reversal of his ileostomy and developed persistent postoperative obstruction. He underwent resection of the prior reversal site with normal-appearing dilated proximal bowel loops and collapsed distal bowel loops. He again developed an obstructive picture and underwent resection of the prior anastomosis with creation of an ileocolic anastomosis, after which he recovered well postoperatively. CONCLUSION: In patients who receive radiation adjuvant therapy for colon cancer, radiation-induced stricture should be considered as a cause of small bowel obstruction postoperative. In the setting of a longstanding ileostomy, evaluation of a defunctionalized distal ileum may be necessary to evaluate potential obstruction from radiation changes.

Avoidance of general anesthesia for circumcision in infants under 6 months of age using a modified Plastibell technique.

PURPOSE: There is currently no gold standard for the type of analgesia or preferred circumcision technique in infants requiring circumcision after 1 month of age. Our study presents a modified Plastibell circumcision technique, which offers excellent surgical outcomes, and can be performed under local anesthesia until 6 months of age, thereby avoiding the risks of general anesthesia in delayed circumcision. METHODS: This is a retrospective case series of 508 consecutive male infants between 1 and 6 months of age, from one institution, who all underwent circumcision under local anesthesia, performed by the same pediatric surgeon, from 2013 to 2018. The study parameters included postoperative complications such as re-operation for control of hemorrhage, wound infection, circumcision revision, and urethral meatotomy. RESULTS: There were no re-operations for control of hemorrhage, no wound infections, and no circumcision revisions. One patient developed urethral meatal stenosis requiring urethral meatotomy. CONCLUSION: Our modified Plastibell circumcision technique under local anesthesia is a safe and reproducible alternative for infants between 1 and 6 months of age, whose parents desire circumcision and wish to avoid general anesthesia.

Defense from the Group A Streptococcus by active and passive vaccination with the streptococcal hemoprotein receptor.

BACKGROUND: The worldwide burden of the Group A Streptococcus (GAS) primary infection and sequelae is considerable, although immunization programs with broad coverage of the hyper variable GAS are still missing. We evaluate the streptococcal hemoprotein receptor (Shr), a conserved streptococcal protein, as a vaccine candidate against GAS infection. METHODS: Mice were immunized intraperitoneally with purified Shr or intranasally with Shr-expressing Lactococcus lactis. The resulting humoral response in serum and secretions was determined. We evaluated protection from GAS infection in mice after active or passive vaccination with Shr, and Shr antiserum was tested for bactericidal activity. RESULTS: A robust Shr-specific immunoglobulin (Ig) G response was observed in mouse serum after intraperitoneal vaccination with Shr. Intranasal immunization elicited both a strong IgG reaction in the serum and a specific IgA reaction in secretions. Shr immunization in both models allowed enhanced protection from systemic GAS challenge. Rabbit Shr antiserum was opsonizing, and mice that were administrated with Shr antiserum prior to the infection demonstrated a significantly higher survival rate than did mice treated with normal rabbit serum. CONCLUSIONS: Shr is a promising vaccine candidate that is capable of eliciting bactericidal antibody response and conferring immunity against systemic GAS infection in both passive and active vaccination models.